5.  The applicant was born in 1962 and lives in L.
6.  For several years the applicant had been under the supervision of, and had been receiving various types of financial assistance amounting to some 600 Croatian kunas (HRK) per month from, a local social care centre.
7.  In June 2008, the applicant’s family doctor submitted to the social care centre a report on her medical treatment, stating as follows:
“With regard to your question concerning Ms M.S.’s state of health and treatment and my observations on her health problems ... I confirm that she has been my patient since March 2008. She is a person with polymorphic health issues, and, in terms of the somatic aspect of her state of health, abdominal sensations related to the gynaecological area (a gynaecologist has prescribed surgery, which the patient constantly refuses) and thereby related anaemia – of course, treated by an alternative therapy.
Because of a number of other health issues (frequent headaches, lumbar pain) she has been sent for specialist examinations, which attested to a sufficiency of outpatient treatment, in the form of both medication and physiotherapy.
Unfortunately, the patient has her own peculiar interpretation of her health issues, on which she insists, and therefore I consider that the best help for her would be psychological/psychiatric treatment. Of course, this requires her consent, which so far could not be obtained. The continuity of the treatment is additionally hampered by the patient’s change of her place of residence. Her visits to the doctor are random, and so are her wishes as to the scope and area of treatment.
The particular difficulty in the medical treatment of Ms [M.]S. is related to her mental [state].”
8.  On 26 June 2008 the social care centre instituted proceedings in the competent court for divesting the applicant of legal capacity, which was one of the issues giving rise to a case before the Court in M.S. v. Croatia (no. 36337/10, §§ 40-46, 25 April 2013).
9.  Following an expert report of 19 August 2013 indicating that the applicant had been effectively engaged in psychiatric treatment, which had been progressing well, on 9 September 2013 the social care centre withdrew the request to divest her of legal capacity.
10.  On 29 October 2012 the applicant went to see her family doctor complaining of severe lower-back pain. Her doctor, after having examined her, called the emergency health service and sent the applicant for some further medical checks.
11.  The doctor who received the applicant in the emergency service found that her general condition was good, that she was conscious and well oriented, but that she had difficulty moving. The doctor made a working diagnosis of lumbago and sent the applicant for further medical checks by a neurologist.
12.  The neurologist in the emergency service examined the applicant on the same day and found that the information she was giving was incoherent and disproportionate to her pain, and that she had not been taking her medication. He made a diagnosis of back pain and anxiety disorder, and sent the applicant for a further examination by a psychiatrist.
13.  The applicant was then examined by a psychiatrist in the emergency service who after interviewing her found that she was making fanciful and confusing allegations of persecution by various doctors. The psychiatrist made a diagnosis of acute psychotic disorder, systemic delusional disorder and delusional dysmorphic disorder, and prescribed hospitalisation.
14.  The applicant was immediately admitted to the psychiatric clinic of the R. Clinical Hospital Centre (Klinički bolnički centar R., Klinika za psihijatriju; hereinafter: “the hospital”), a public health-care institution. The relevant parts of the admission record, in so far as legible, indicate as follows:
“Date of admission: 29.10.2012 Date and time of hospitalisation: 29.10.2012
...
Admission diagnosis: ... anxiety disorder
...
Patient’s attitude towards the examination: refused examination by a psychiatrist; requested a somatic examination
...
Psychological condition: conscious and well oriented, suspicious ... tense in the psychomotor sense ... distanced, cold, with ideas of ... persecution, control ...
Neurological condition: syndrome of back pain
...
Patient’s attitude towards the hospitalisation: refuses
Consent: NO
...
Physical intervention: physical restraint, tying to a bed
...”
15.  In the evening of the same day, another doctor examined the applicant. The relevant part of the examination record reads:
“The patient was hospitalised after an examination by Dr [T.]L., and after having been treated in the [emergency ward] for persistant severe back pain (documentation in attachment).
She was brought on a stretcher, tied down, maintaining conscience and orientation, negative, arguing, yelling, agitated, affectively dissolute, with a mind-flow disorder, substantively paranoid ideas. ...
Diagnosis: Acute psychotic disorder F 23.2
Delusional disorder ...
Fixation. Th. according to the list.”
16.  According to the applicant, following her admission to hospital she was tied to a bed with four belts tightened around her ankles and wrists, and forcefully injected with a strong drug. She was kept in that position throughout the night and felt severe pain in her back. Her left leg was restrained in such a position that the belts caused her additional pain. The room was small and had no windows. The following morning the belts were removed and she was taken to another room in the psychiatric hospital.
17.  According to the Government, following the applicant’s admission to hospital she was given the usual treatment for patients in a state of psychotic agitation and was then placed in an isolation room. The room had a direct connection with the adjacent staff room and was under constant video surveillance. The room measured 2.50 by 2.12 metres and the height of the ceiling was 3.15 metres. It was equipped only with one bed. It had a heating and air-conditioning system, as well as access to sanitary facilities. The belts used to restrain the applicant to the bed were specially adapted so as to avoid any injuries.
18.  The Government further explained that the applicant had been tied to the bed in the isolation room from the time of her admission to hospital at 8.50 p.m. on 29 October 2012 until the next morning. She was then taken to a regular hospital room where she was again restrained until 12 noon. During that time her condition and all her needs were regularly monitored. After the initial period following the applicant’s admission to hospital until her release, she was not restrained again.
19.  The available medical records concerning the physical restraint used on the applicant in the hospital show that this method was used in the period between 8.50 p.m. on 29 October 2012 until around 12 noon on 30 October 2012. The relevant medical record monitoring the applicant’s physical restraining, in so far as legible, reads as follows:
“29/30.10
– brought by [the emergency service] on a stretcher ...
– upon admission screaming, restive, kicking
– came [to the emergency service] because of back pain
– taken to the isolation box (hands and legs fixed), screaming, threatening, restive
...
– psychotic, paranoid [ideas]
– drunk water
– complains of lower back pain
– did not sleep well during the night, called [for assistance], drunk water (approximately one litre) ...
– manipulative
– did not sign the consent to hospitalisation, ... 30.10.2012
– morning hygiene performed in the box
– ... around 12 p.m. taken to the intensive care ward ... complains of back pain, unaware of her condition, paranoid ...”
20.  On 30 October 2012 the hospital informed the R. County Court (Županijski sud u R.) that the applicant had been involuntarily admitted for treatment on 29 October 2012, that she had refused further hospitalisation and that her mental condition prevented her from making a sound decision in that respect.
21.  On the same day the R. County Court instituted proceedings for the applicant’s involuntary retention and appointed a legal-aid lawyer, P.R., to represent her.
22.  On 31 October 2012 the judge conducting the proceedings visited the applicant in the hospital. The record of the visit in its entirety reads:
“[Number of the case file]
OFFICIAL NOTE
On 31 October 2012 the judge conducting the proceedings visited the respondent M.S. in hospital and interviewed her. She stated that because of back-pain problems on 29 October 2012 she had visited her family doctor in L., but then she had been placed in hospital by subterfuge.
She alleged that she had learned that she and several other patients would be used for ‘practising’ by some foreign doctors. When asked by the judge she replied that her parents were not alive, that she was not married and did not have children, and that she had a sister living near her in L.
During the conversation she stated that she had never been previously treated in a psychiatric hospital.
In R., 31 October 2012
 
[Signature]”
23.  On the same day the judge provisionally extended the applicant’s involuntary retention until 6 November 2012. The judge also commissioned a psychiatric expert report concerning the applicant’s mental state and scheduled a hearing for 6 November 2012, to which he invited the applicant’s representative, P.R., and the expert.
24.  At the hearing on 6 November 2012 the expert submitted a psychiatric report drawn up on 2 November 2012 whereby he found, based on the medical documentation relevant to the applicant’s admission to hospital and an interview with her, that she had manifested a psychotic disorder amounting to a serious mental illness. He also considered that the applicant’s release from the hospital could seriously endanger her health and that it was absolutely necessary to order her involuntary retention for a further month. The hearing lasted in total ten minutes. The applicant’s representative and the judge conducting the proceedings had no questions for the expert.
25.  On the same day the R. County Court ordered the applicant’s involuntary retention in the hospital until 28 November 2012, with the following statement of reasons:
“On 30 October 2012 the [hospital] informed [this court] that the respondent had been involuntarily admitted to that institution. It submitted the relevant medical documentation as required under section 27 of the Protection of Individuals with Mental Disorders Act (Official Gazette nos. 11/1997, 27/1998, 128/1999 and 79/2002).
When deciding on the necessity of the respondent’s involuntary retention and its duration, [this court] commissioned an expert report from Dr A.Č., a neuropsychiatrist from R.; examined the medical documentation; and the judge responsible for the case visited and interviewed the respondent in [the hospital].
Based on the examination of the respondent and the medical documentation, the expert found that she was demonstrating symptoms of a manifest psychotic disorder, that she had a serious mental disorder and that her release [from hospital] at this stage would seriously endanger her health.
Thus the expert considered that the respondent absolutely needed treatment in a psychiatric hospital for the duration of a month ...
The respondent’s representative had no objections to the expert report, and this court also considers that the report is adept and objective and in compliance with other documentation from the case file.
Given that the conditions for the respondent’s involuntary retention in hospital have been met, within the meaning of sections 22(1) and 33(3) of the Protection of Individuals with Mental Disorders Act, it was decided as noted in the operative part of this decision.”
26.  The decision was served on the applicant and her legal-aid representative, the hospital and the competent social care centre.
27.  On 7 November 2012 the applicant lodged an appeal against the above decision before a three-judge panel of the R. County Court, arguing that there was no reason for her confinement in a psychiatric hospital. She also stressed that at the time of lodging the appeal she was under strong medication.
28.  On 9 November 2012 the applicant’s sister, explaining that she was acting on behalf of the applicant because the applicant was under strong medication, lodged a further appeal before a three-judge panel of the R. County Court. She contended that the applicant had been suffering from serious back pain and because of that had visited her doctor. However, she had been forcefully taken to the psychiatric hospital. In the hospital she had been tied to a bed and had spent the entire night in agony because of the severe lower-back pain. Furthermore, she complained that nobody had ever explained to the applicant the relevant procedure and that she had realised only later that one of the persons who had visited her in the hospital was a judge. She also stressed that the legal aid lawyer had not visited the applicant during the proceedings. This appeal was signed by the applicant and her sister.
29.  The applicant addressed a handwritten complaint to the director of the hospital and the director of the R. Clinical Hospital Centre, dated 8 November 2012, which was attached to the above appeal (see paragraph 28 above). She complained that she had been tied to a bed in the hospital without any reason and in violation of her human dignity. She also stressed that nobody had taken into account her lower-back pain problems, or explained to her the relevant procedure. She further contended that her legal aid lawyer had never visited her and that her internment in the hospital had been contrary to the relevant domestic law and had even raised issues of criminal responsibility.
30.  The applicant’s complaint was never forwarded to the hospital’s director or any other competent hospital authority.
31.  On 13 November 2012 a three-judge panel of the R. County Court dismissed the appeals as ill-founded, endorsing the findings of the first-instance court. The relevant part of the decision reads:
“It has been established in the case at issue that the respondent had lacked the capacity to make a critical assessment of her condition and illness and that she had been diagnosed with an acute psychotic disorder (F23.2) and systemic delusional disorder (F22.I.O.) Furthermore, it was established that the respondent had been tense in the psychomotor sense, affectively cold, dissociated, and that she had manifested a number of psychopathological conditions such as derealisation, depersonalisation, paranoid systemic ideas of persecution, pressure and control, that she had lacked the capacity to make a critical assessment of her condition, and that her release from hospital could seriously endanger her health. This court finds that this satisfies the requirements under section 22(1) of the Protection of Individuals with Mental Disorders Act, providing for the possibility of involuntary treatment.
The above considerations, in particular the respondent’s state of health, as well as her appeal arguments, suggest that she is unable to make a critical assessment of her condition, and therefore this court considers that her release at this stage could seriously endanger her health.
As to the arguments concerning the breach of the respondent’s rights and inadequate medical treatment, she is instructed to forward her complaints to the State Board for the Protection of Individuals with Mental Disorders within the Ministry of Health and the Hospital’s Ethical Board.”
32.  This decision was served on the applicant and her sister, the applicant’s legal aid representative, the hospital and the competent social care centre. However, from the case file it does not appear that any further action was taken.
33.  On 14 November 2012 the applicant sent a letter to the hospital’s director expressing her satisfaction with the hospital diet.
34.  On 3 December 2012 the hospital informed the R. County Court that the applicant had been discharged from hospital on 29 November 2012.